Another Boost for Minimally Invasive Surgery

by Michael Smith Michael Smith North American Correspondent, MedPage Today
April 16, 2012

Action Points

For most types of abdominal surgery, an open procedure appears to increase the risk of later small bowel obstruction compared with laparoscopy.

Point out that multivariate analysis revealed age, previous surgery, comorbidity, and surgical technique to be risk factors for small bowel obstruction.

For most types of abdominal surgery, an open procedure appears to increase the risk of later small bowel obstruction, compared with laparoscopy, researchers reported.

In a population-based study, the incidence of small bowel obstruction, owing to adhesions, ranged from 0.4% to 13.9% depending on the procedure, according to Eva Angenete, MD, PhD, of Sahlgrenska University Hospital/Ostra in Gothenburg, Sweden, and colleagues.

But with the exception of bariatric surgery, the risk of small bowel obstruction was higher with open surgery than laparoscopy, Angenete and colleagues reported in the April issue of Archives of Surgery.

Small bowel obstruction, a common reason for emergency admission, is caused by adhesions that develop after peritoneal trauma, such as abdominal surgery, the authors noted. Laparoscopic procedures are associated with less surgical trauma, which might imply a lower risk of such adhesions, they added.

To investigate, they turned to a nationwide database of discharge diagnoses and registered surgical procedures in Sweden from Jan. 1, 2002, through Dec. 31, 2004.

Patients identified as having one of a range of procedures -- including hysterectomy, salpingo-oophorectomy, bowel resection, anterior resection, and bariatric surgery -- were followed for 5 years or until death to discover the incidence of small bowel obstruction.

All told, the researchers identified 108,141 patients and conducted a multivariate analysis to gauge the impact of risk factors including age, sex, previous surgery, presence of comorbidity, and whether the procedure was open or laparoscopic.

Each of the risk factors had significant effects in some procedures and not in others, although in almost all cases the risk associated with open versus laparoscopic surgery was much greater, the researchers found.

For instance, the odds for small bowel obstruction after salpingo-oophorectomy were significantly increased for each year of age and for previous surgery (with odds ratios of 3.5 and 1.9, respectively).

But the odds ratio for obstruction, given open versus laparoscopic surgery, was 7.6 (95% CI 4.4 to 13.1), which was significant at P<0.001.

In all cases except bariatric surgery, the odds ratios were increased for the open procedure, although some did not reach significance. But for bariatric surgery, the odds ratio was decreased, although it was also nonsignificant, at 0.7 (95% CI 0.4 to 1.2).

The researchers noted that the study was not a randomized clinical trial, but added it included a large number of patients and was population-based. As well, they noted, the external validity is high for surgical procedures and there's no reason to expect biased reporting of any of the risk factors.

For surgeons, the study "highlights another potential benefit of minimally invasive surgery and challenges us to continue to offer less invasive procedures whenever they are feasible." commented Luke Funk, MD, and Stanley Ashley, MD, both of Brigham and Women's Hospital in Boston.

For patients, the findings offer lower morbidity and improved quality of life, while payers and policy-makers have the prospect of lower costs, they added in an accompanying comment article.

One complication is that it may be difficult in some payment models to account for the higher initial cost of laparoscopy but lower long-term cost, they noted.

The study had support from the Swedish Cancer Foundation, the Swedish Medical Association, the Gothenburg Medical Association, the Assar Gabrielsson Foundation, the Magn Berwall's Foundation, and the Swedish Research Council. The journal said the authors did not report any financial disclosures.

The journal said the comment authors did not report any financial disclosures.

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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